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Current therapeutic approaches for plantar fasciitis

Article  in  Orthopedic Research and Reviews · March 2014


DOI: 10.2147/ORR.S43126

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Current therapeutic approaches


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Nicolò Martinelli Abstract: Almost 1 million Americans are affected by plantar fasciitis (PF), which is the
Carlo Bonifacini commonest cause of chronic heel pain. This condition is often managed conservatively, and
Giovanni Romeo many rehabilitation protocols, some with the aid of orthoses, have been adopted, with good-
to-excellent clinical results. Although most cases of chronic PF can be successfully managed
Department of Ankle and Foot
Surgery, IRCCS Galeazzi Orthopaedic with a conservative approach, alternative treatments, including high-energy shock wave therapy
Institute, Milan, Italy and corticosteroid injections, are commonly accepted as second-line treatment when traditional
conservative therapy fails. However, surgery is still an important mode of treatment. Recently,
new minimally invasive surgical techniques that offer numerous advantages (faster recovery
time, early weight-bearing, lower postoperative pain) over standard surgical approaches have
been proposed, with good results and low complication rates. The purpose of this review is to
report new conservative and surgical techniques for the treatment of PF. A literature search
for articles about plantar fasciitis was conducted on the PubMed database in order to identify
publications addressing the treatments of PF. The literature suggests that, initially, traditional
conservative treatments consisting of rest, oral nonsteroidal anti-inflammatory drugs, foot orthot-
ics, and stretching exercises can be tried for several weeks. In patients with chronic recalcitrant
PF, extracorporeal shock wave therapy or corticosteroid injection can be considered. Surgery
(minimally invasive techniques) should be considered only after failure of the conservative
treatments.
Keywords: heel pain, surgery, plantar fasciosis

Introduction
Plantar fasciitis (PF) is a common cause of heel pain seen by foot and ankle surgeons.
Approximately 10%–16% of the US population suffers from PF, and approximately 75%
of these patients turn to their family physician.1,2 The term “plantar fasciitis” has been
used for years, but this term is misleading since inflammatory cells are rarely present
in biopsies from involved fascias.3 Therefore, Lemont et al advocate the term “plantar
fasciosis” to describe the syndrome characterized by pain along the proximal plantar
fascia and its attachment in the area of the calcaneal tuberosity with impaired physical
function, implying a more chronic degenerative process in comparison with acute heel
pain.3 In literature, the term “plantar heel pain syndrome” has been used for patients with
PF. We believe this term is too generic and should be used only for plantar heel pain. In
Correspondence: Nicolò Martinelli
Department of Ankle and Foot Surgery,
this review, we will use the term “plantar fasciitis” to refer to the presentation of patients
IRCCS Galeazzi Orthopaedic Institute, with plantar fasciopathy and facilitate the comparison between studies reported.
Via R Galeazzi 4, 20100 Milan, Italy
Tel +39 02 662 141
The plantar fascia is formed from collagen fibers that originate from the medial
Email n.martinelli@unicampus.it tuberosity of the calcaneus and insert into the dorsal aspect of the proximal phalanges

submit your manuscript | www.dovepress.com Orthopedic Research and Reviews 2014:6 33–40 33
Dovepress © 2014 Martinelli et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0)
http://dx.doi.org/10.2147/ORR.S43126
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and the flexor tendon sheaths.4 A number of studies have of hypesthesia or dysesthesia, and assessment of the forefoot/
shown that the plantar fascia is involved in both the dynamic midfoot/hindfoot alignment. Passive ankle/first-toe dorsi-
and static supports of the arch of the foot.5–8 During weight- flexion can cause discomfort or pain in the proximal plantar
bearing, stretching of the longitudinal arch is prevented by fascia and it can also cause painful tightness of the Achilles
tension of the plantar fascia, muscles, and ligaments, with tendon. A fall from a height onto the heel may cause bone
compression of the bones forming the arch itself.8 C ­ ontinuity fractures involving the subtalar joint, the sustentaculum
of the plantar fascia into the paratenon of the Achilles tendon tali, the plantar calcaneal tubercles, or the inferior calcaneal
has been shown in cadaver specimens, providing a positive spur. In most cases, diffuse pain in the hindfoot is poorly
correlation between Achilles tendon loading and plantar localized in the heel itself.15 A fracture is usually suspected
fascia tension.6 In cadaver studies, complete release of the with a history of trauma and focal pain at palpation. Acute
plantar fascia decreased the height of the medial longitudinal plantar fascia rupture should be suspected in patients with a
arch during terminal stance as well as changed the distribu- history of trauma and with negative radiographic and bone
tion of plantar foot pressure, resulting in increased pressure scan findings. Plantar swelling and ecchymosis of the heel
on the central metatarsal heads.9–11 are often present.16–18
The etiology of PF is likely multifactorial. Numerous
factors, including flatfoot, advancing age, obesity, inappropri- Differential diagnosis
ate footwear, and decrease in ankle dorsiflexion, have been The differential diagnosis of plantar heel pain includes
associated with plantar fascia disorders.2,12,13 While advanc- significant disorders, such as calcaneal stress fracture,
ing age, which may induce plantar fascia degeneration and systemic arthritides, entrapment neuropathies (eg, tarsal
increased mechanical overload, is considered a risk factor tunnel syndrome and medial plantar nerve entrapment),
for PF, the true pathogenesis remains unknown. A literature calcaneal infection, plantar calcaneal bursitis, or hindfoot
search for “articles about plantar fasciitis” was conducted osteoarthritis.19 Taking patient history, performing a physical
on the PubMed database in order to identify publications examination of the foot and ankle, and ordering appropriate
addressing the current treatments of PF. Randomized clini- imaging studies, if indicated, are the first steps to making the
cal trials, case series, surveys, and narrative reviews written correct diagnosis. A calcaneal stress fracture often develops
in English and published in peer-reviewed journals were from repetitive overload to the heel, and most commonly
included in this study. Although a more valid approach occurs when muscles become fatigued and are unable to
requires systematic search strategies, the intention of this absorb added shock. Patients experience heel pain after an
review is to describe the current therapeutic approaches and increase in weight-bearing activity or change to a harder
the context in which future studies should be situated. walking surface. The pain initially occurs only with activity,
but often progresses to include pain at rest. Clinically, first
Clinical presentation examination may reveal swelling and stiffness associated
Patients with PF will complain of plantar heel pain, which is with point tenderness at the fracture site immediately inferior
exacerbated with the first step after a period of non-weight- and posterior to the posterior facet of the subtalar joint.19,20
bearing, typically in the morning. In the early stages, patients Magnetic resonance imaging (MRI) allows evaluation of
will report that their symptoms improve after a few steps or the extent of a stress fracture, as well as assessment of the
minutes, but, in the chronic stages, pain becomes blunt and ligamentous structures and plantar surface.20,21
constant.14 Paresthesia presenting as burning, tingling, or numbness
The condition is generally self-limiting, and most of the with chronic unilateral pain is indicative of neurologic heel
cases spontaneously resolve regardless of the type of inter- pain due to nerve entrapment. These symptoms most com-
vention received (including placebo). The painful symptoms monly indicate a neuropathic etiology caused by overuse,
usually spontaneously resolve within 10 months.14 However, trauma, obesity, venous insufficiency, or iatrogenic injury
in approximately 10% of patients, the disease progresses to from previous surgery.22,23 Tarsal tunnel syndrome is the most
chronic pain.14 Physical examination commonly reveals pain commonly reported nerve entrapment due to compression of
at palpation of the plantar fascia at the plantar aspect of the branches of the posterior tibial nerve, including the medial
calcaneal tuberosity. Physical examination should, however, plantar nerve, the lateral plantar nerve, or the nerve to the
include the assessment of range of motion of the foot and abductor digiti minimi.22–25 Decreased heel pad elasticity
ankle, focusing on limitation of ankle dorsiflexion, presence with aging and increasing body weight may cause heel pad

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Dovepress Treatment for plantar fasciitis

syndrome, which is often mistaken for PF. The syndrome is riovenous malformation, and calcaneal stress fracture can be
usually caused by inflammation, but damage to or atrophy detected with MRI.43 The high cost of this exam should be
of the heel pad can also elicit deep pain in the middle of the taken into account, hence MRI is indicated only in patients
heel, which can be reproduced with firm palpation.26 with recalcitrant atypical heel pain. Other examinations, such
as computerized tomography scanning, technetium-99m bone
Imaging scan, nerve conduction velocity, and electromyography test,
Plain weight-bearing radiographs of the foot represent the are indicated for those patients with a high index of suspicion
initial imaging study. Radiologic studies generally do not for the other causes of heel pain.
add additional diagnostic information, but they can exclude
alternative causes of plantar heel pain or can be used in assess- Therapy
ment of a failed treatment. A heel spur is often detected in Nonoperative treatment
radiographs of the foot; however, its presence may not nec- Conservative therapies remain the preferred approach to
essarily correlate with the patient’s symptoms, since people treating PF, successfully managing 85%–90% of cases
without any symptoms can have this radiographic finding.27–30 (Table 1).44,45 A 2010 clinical practice guideline from the
Although ultrasonography and MRI are not the current imaging American College of Foot and Ankle Surgeons recom-
modalities of choice in patients with PF, they can provide useful mends conservative treatments, such as nonsteroidal
information.31,32 Ultrasonography is an inexpensive diagnostic anti-­inflammatory drugs (NSAIDs), specific plantar fascia
tool, which can be used to assess soft tissue pathology of the stretching, and orthotics for the initial management of
heel. Normal plantar fascia is hyperechoic and isoechoic with plantar heel pain.46 Patients should be informed that it may
adjacent fat, with a thickness ranging from 2–4 mm.33 A thick- take 6–12 months for symptoms to resolve. Patient-directed
ening of the fascia greater than 4 mm and areas of hypoecho- treatments to improve heel pain consist of rest, activity
genicity can be observed in patients with plantar fasciopathy, modification, ice, and acetaminophen or NSAIDs. A ran-
which directly correlates with heel pain.13,34,35 Other signs of domized placebo-controlled prospective study of NSAIDs
plantar fasciopathy include loss of definition and disorganiza- to treat chronic PF showed short-term improvement in pain
tion of the plantar fascia structure and peri-insertion edema.36 relief and disability when combined with other conservative
Ultrasound should also be used to identify the precise localiza-
­
treatments.47 However, there are few studies to support the
tion of corticosteroid injection within the plantar fascia and benefits of these treatments used alone.
may be used as an objective measure of response to treatment The use of foot orthoses (prefabricated or custom-made)
in PF.37–39 Recently, Ieong at al reported the results of ultrasound is considered the commonest approach in patients with PF.48
evaluation in 125 consecutive feet with symptoms of chronic Orthoses theoretically unload the plantar fascia, reducing foot
PF and concluded that distal involvement of the plantar fascia pronation. Because of the moderate expense, it is suggested
with atypical pattern ­(fusiform thickening of the plantar fascia that they should not be prescribed routinely to all patients but
distal to the insertion with normal appearance at the insertion should be used instead in cases of abnormal foot posture (eg,
site) is frequently observed.40 Therefore, the authors suggested flat feet). Lee et al performed a meta-analysis examining the
the use of ultrasonographic examination in cases of recalcitrant effects of foot orthoses on self-reported pain and function in
plantar heel pain that have residual pain after conservative first- patients with PF and found that foot orthoses can decrease
line management, in order to confirm the clinical diagnosis and rear foot pain and improve foot function.49 A Cochrane Review
to classify the disease as either insertional or noninsertional found that custom foot orthotics may not help to reduce foot
plantar fasciopathy (or mixed disease).40 MRI has been shown pain any more than prefabricated foot orthotics, but, when cus-
to differentiate between the various causes of heel pain, due tom foot orthotics are used with an anterior night splint, patients
to its ability to identify soft tissue and bony anatomy of the may show higher pain relief.50 It is a generally held consensus
plantar aspect of the foot.41 In patients with PF, the commonest that one or more of these options should be started prior to
findings are perifascial and calcaneal bone edema with high initiating any invasive treatments (level II evidence; Table 1).
signal intensity within the plantar fascia on T2 and short-tau A recent paper reported good results with either full-length
inversion recovery images and thickening of the plantar fascia silicone insoles for patients with PF or an ultrasound-guided
greater than 5 mm on T1 sequences.42 However, in patients with corticosteroid injection.51 Plantar fascia-specific stretching
atypical chronic heel pain, osteoarthritic changes of hindfoot/ exercise has shown good results in the treatment of chronic
midfoot joints, regional migratory osteoporosis, plantar arte- PF.14,52–54 This approach for treatment of PF is simple and

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Martinelli et al Dovepress

Table 1 Evidence for management of plantar fasciitis


Grade of Level of Treatment Comments
recommendation evidence
A I PFSS Strong evidence: several multicenter RCTs have shown good
results based on an effective, inexpensive, and straightforward
treatment.14,52–54
ESWT Strong evidence: multiple meta-analyses of RCTs showed that
ESWT decreases pain and improves function.59–63
B II–III Orthotics Moderate evidence: use of silicone insoles or custom foot
orthotics. Systematic reviews but RCT evidence lacking.48–51
NSAIDs Moderate evidence: short-term improvement in pain relief and
disability. Systematic reviews but RCT evidence lacking.46,47
Corticosteroid injections Moderate evidence: acceptable first-line treatment.
Observational or controlled trials with several limitations.65–71
Radiotherapy Moderate evidence: therapeutic alternative for painful heel
spur. Retrospective studies and RCTs.88,90,91,94
C IV PRP injections Weak evidence: PRP has been shown to be safe and effective
in reducing pain scores and improving function. Case series
based on clinical experience and expertise.9,78,79
Plantar fasciotomy or Weak evidence: second-line treatment for chronic plantar
gastrocnemius recession fasciitis. Retrospective studies and case series with several
limitations.46,97,98,101–104,111,113
Notes: The three-category system of quality of evidence was chosen: “strong” (Grade A), “moderate” (Grade B), and “weak” (Grade C) The strongest evidence comes from
multicenter RCTs or meta-analyses of RCTs. The moderate strength category is populated by systematic reviews, retrospective studies or controlled trials with important
limitations and by exceptionally strong observational studies. Case series and on occasion retrospective studies with multiple serious limitations, will fill the weak quality
evidence category.
Abbreviations: ESWT, extracorporeal shock wave therapy; NSAIDs, nonsteroidal anti-inflammatory drugs; PFSS, plantar fascia-specific stretching; PRP, platelet-rich plasma;
RCT, randomized controlled trial.

inexpensive; however, recommendations for the optimal (ie, calcaneal spur) may be successfully treated with a “stimu-
duration and frequency of stretching exercises have not been lating” approach, such as ESWT. Rompe et al have previously
unanimously established (Figure 1). The results, obtained reviewed the results of using focused shock wave therapy to
from good experimental studies,14,52–54 suggest this treatment treat chronic PF in a meta-analysis.62 Despite the heterogeneity
protocol for the treatment of chronic proximal PF. In a 2011 between the studies included in their work (method of shock
study, adding myofascial trigger-point manual therapy to a wave generation, amount of shock wave energy delivered, use
plantar fascia-specific stretching exercise routine improved of anesthesia, and outcome measure), the authors concluded
self-reported pain and function when compared to stretching that ESWT should be considered for the treatment of plan-
alone.55 ­However, due to the absence of a true control/sham/ tar fasciopathy when more common, accepted, and proven
placebo group and long-term follow-up, the trigger-point noninvasive treatments have failed. A  2012 review article
release techniques cannot be considered effective in the treat- concluded that most research shows that ESWT decreases pain
ment of heel pain. and improves function in 34%–88% of patients with chronic
Patients with severe pain when arising from bed in the PF.60 Dizon et al, in a more recent meta-analysis, combined
morning can achieve benefits from the use of a night splint, the results of eleven studies on the effects of ESWT on PF and
which can provide a stretch lasting for many hours. Poor reported a decrease of pain and improved function in patients
compliance should be taken into account, especially for with chronic PF.63 Therefore, ESWT should be recommended
patients with a low quality of nighttime bed rest. as a remedial measure after failure of traditional conservative
Extracorporeal shock wave therapy (ESWT) has been treatment and before surgical intervention. Recently, one study
used to treat different orthopedic disorders, including PF, reported comparable results between high-energy ESWT and
shoulder calcific tendinitis, lateral epicondylitis, and Achilles endoscopic plantar fasciotomy at short-term follow-up (1
tendinopathy.56–60 Shock waves used to treat PF are hypoth- year).64 However, larger randomized controlled studies are still
esized to improve pain relief by promoting extracellular needed to compare the curative effect of ESWT with surgery
responses that cause neovascularization and angiogenesis lead- in the treatment of recalcitrant PF.
ing to tissue repair and regeneration.61 Theoretically, patients Corticosteroid injections have been used to treat multiple
with plantar fasciopathy with degeneration and calcific change orthopedic diseases, including acute and chronic tendon

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Dovepress Treatment for plantar fasciitis

proposed in recent years, including a micronized dehydrated


human amniotic/chorionic membrane injection or botulinum
toxin type A injection, with satisfactory results, but more
studies are needed to include such protocols in the first-line
approach for recalcitrant PF.80–85
Cast immobilization for 4–6 weeks or use of a short-
leg walking boot to immobilize or offload the foot during
activity has been proposed for recalcitrant PF, but the
lack of prospective randomized studies precludes specific
recommendations.86,87
A further modality for the treatment of painful PF is
radiotherapy.88–92 Radiotherapy in nonmalignant disease is
effective because the anti-inflammatory activity is mediated
by a mechanism of downregulation of leukocyte adhesion and
nitric oxide synthase activity in stimulated ­macrophages.93
In a retrospective study, Miszczyk et  al reported lack of
pain in 157 of 327 (48%) patients without a dose–response
relationship.88 In a more recent multicenter randomized
controlled trial on the effect of radiation therapy on PF,
Niewald et  al demonstrated that radiation therapy with
6.0 Gy doses applied in six fractions of 1.0 Gy twice weekly
(standard dose) was highly significantly superior to low-dose
Figure 1 Plantar fascia specific stretching. radiation therapy (0.6 Gy applied in six fractions of 0.1 Gy
twice weekly).94 Considering the lack of adverse effects, the
pathologies.65,66 A single dexamethasone injection has been simplicity of treatment, and the safe modality, radiotherapy
proven to reduce pain and improve function in patients with seems to be an effective treatment for PF.
plantar fasciopathy.66–68 Additionally, the American College of
Foot and Ankle Surgeons considers corticosteroid injections an Surgical treatment
acceptable first-line treatment for PF.46 Complications such as Surgery should be considered only for patients who have
plantar fascia calcification, post-injection pain, fat pad atrophy, not responded adequately after 6–12 months of conserva-
and plantar fascia ruptures should be taken into account.69–71 tive therapy.95 Surgery typically includes open plantar
Steroid injection immediately after endoscopic surgery fasciotomy, resection of the heel spur (when present), and
has been suggested to decrease postoperative fibrosis.71,72 release of the abductor hallucis fascia.96,97 Complications
Recently, promising clinical results have been reported with of open surgery include residual pain (approximately
the use of platelet-rich plasma (PRP) injections for treating 25% of patients will still experience heel pain); flatfoot
chronic muscle and tendon injuries.73–76 The rationale for using deformity due to over-release of the plantar fascia; medial
PRP is to promote cellular chemotaxis, matrix synthesis, and calcaneal nerve damage; and plantar tender scar.95 Several
proliferation through higher than physiologic doses of repara- studies have investigated open plantar fasciotomy through
tive growth factors.77 PRP has been shown to be safe and effec- a variety of approaches.98–100 Endoscopic plantar fascia
tive in reducing pain scores and improving function in chronic fasciotomy, performed through a small skin incision, has
PF.9,78 It can be argued that steroid injections, which decrease been proven to achieve better results in comparison to
the inflammatory state of the tissue, are more successful in traditional open surgery, and current practice suggests a
PF than in plantar fasciopathy. In a recent paper, Akşahin et al minimally invasive approach to plantar fasciotomy ver-
compared the use of PRP injection with methylprednisolone sus extensive open surgical exposures.46,101–103 The use of
injection, and both treatments were effective and successful endoscopic approaches in performing these procedures
in treating recalcitrant PF with no complications.79 Therefore, allows more rapid recovery and return to activity after
future randomized controlled trials are warranted to confirm or surgery, with a low rate of complications (wound infection,
refute these findings. New conservative treatments have been residual pain). Patients undergoing surgery should expect

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Martinelli et al Dovepress

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